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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.,(209)468-3433 Web:www.siggy.org/ehd <br /> RECORDING REQUIREMENTS <br /> FOR UNAUTHORIZED RELEASES <br /> An owner or operator is required to record all releases from the primary containment, as approved in <br /> this facility's Response Plan. This form may be used to meet the recording requirements* if all of the <br /> conditions below are true. <br /> 1. The owner or operator can clean up the release from the primary containment <br /> within 8 hours after the release was detected or should have been detected. T F <br /> AND <br /> 2. The release has not escaped the secondary containment. T F <br /> AND <br /> 3. The release does not increase the hazard of fire or explosion. T F <br /> AND <br /> 4. The release does not cause deterioration of the secondary containment. T F <br /> If all conditions above are not fulfilled you must report the release to the San Joaquin County <br /> Environmental Health Department and other agencies as appropriate. Date of release: 4/3/2017 <br /> Operator's name: Quik Stop Markets Phone Number: <br /> Facility name: Quik Stop#76 Facility Address: 1030 S. Olive Ave.,Stockton <br /> Hazardous substance found in the secondary containment: Disp#1-2 UDC <br /> Quantity: less then a cup , Concentration: n/a <br /> Description of the actions taken to control and clean up the release: <br /> cleaned with absorbant rags and disposed of hazardous waste drum onsite. <br /> The method and location of disposal of the released hazardous substance:-hazard waste drum <br /> Description of actions taken to repair the LIST and to prevent future releases. Attach a copy of the <br /> maintenance receipt: Notified manager to contact their service company for this site. <br /> Describe how the monitoring system was reactivated after repairs or replacement: <br /> N/A-not enough liquid to shut down the dispenser. <br /> Attach printout from continuous monitoring system, maintenance receipts, manifests, photos,etc. <br /> Retain this document with your monitoring records for review during the annual inspection by our department. <br /> *See the California Code of Regulations, Title 23, Section 2651 and California Health&Safety Code Section <br /> 25294 for further requirements. <br />